New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter II - Administrative Rules and Regulations
Subchapter R - Health Maintenance Organizations
Part 98 - Health Maintenance Organizations
Subpart 98-5
Section 98-5.6 - Access to providers for enrollees

Universal Citation: 98-5.6 NY Comp Codes Rules and Regs § 98-5.6

Current through Register Vol. 47, No. 12, March 26, 2025

(a) If an enrollee is unable to schedule an appointment with a participating provider of behavioral health services within the appointment wait times set forth in section 98-5.5 of this Part because there is not a participating provider of behavioral health services available within the appointment wait times who can treat the enrollee's behavioral health condition, the enrollee, or the enrollee's designee, may submit an access complaint by telephone, and in writing to the MCO to resolve the access issue.

(b) The MCO shall have three business days from receipt of the access complaint to locate a participating provider of behavioral health services that can treat the enrollee's behavioral health condition and is able to meet the appointment wait times set forth in section 98-5.5 of this Part and to give the enrollee or the enrollee's designee the name of and contact information for the provider or providers by telephone, if the request was made by telephone, and in writing. If the enrollee specifically requests an in-person appointment, the provider shall be located within a reasonable distance from the enrollee; however, the distance may be greater for enrollees who reside in rural areas than for enrollees who do not reside in rural areas.

(c) If the MCO is unable to locate a participating provider of behavioral health services that can treat the enrollee's behavioral health condition, is able to meet appointment wait times set forth in section 98-5.5 of this Part, and is located within a reasonable distance from the enrollee if the enrollee specifically requests an in-person appointment, the MCO shall;

(1) notify the enrollee by telephone, if the request was made by telephone, and in writing, at the expiration of the time period in subdivision (b) of this section that the enrollee may obtain a referral to a nonparticipating provider at the in-network cost-sharing and include contact information for the New York State Behavioral Health Ombudsman Program; and

(2) approve a referral to a non-participating provider, regardless of whether the enrollee's coverage includes out-of-network benefits, if the non-participating provider:
(i) can treat the enrollee's behavioral health condition;

(ii) is able to meet the appointment wait times set forth in section 98-5.5 of this Part, as measured from the enrollee's receipt of the notification in paragraph (1) of this subdivision;

(iii) is located within a reasonable distance from the enrollee if the enrollee specifically requests an in-person appointment; and

(iv) charges rates that are not excessive or unreasonable.

(d) The approved referral shall remain in effect until the earlier of the following:

(1) the behavioral health services are no longer medically necessary; or

(2) the MCO locates a participating provider of behavioral health services that can treat the enrollee's behavioral health condition, is able to meet the appointment wait times set forth in section 98-5.5 of this Part and is located within a reasonable distance from the enrollee if the enrollee specifically requests an in-person appointment, and the enrollee's treatment can be transitioned to the participating provider, unless the MCO determines, in consultation with the enrollee's treating provider, as appropriate, that such a transition would be harmful to the enrollee. If the enrollee or the enrollee's designee disagrees with the MCO's transition of care determination, the enrollee or the enrollee's designee may request an expedited determination or appeal pursuant to Public Health Law section 4408-a or 4904, as applicable.

(e) The MCO shall not impose cost-sharing on the enrollee, including a copayment, coinsurance, or deductible, for the service rendered by a nonparticipating provider pursuant to an approved referral, that is greater than the cost-sharing that the enrollee would owe if the enrollee had received services from a participating provider. The MCO shall apply the out-of-pocket maximum that would have applied had the services been received from a participating provider.

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